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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850243
Report Date: 04/03/2025
Date Signed: 04/03/2025 04:45:26 PM

Document Has Been Signed on 04/03/2025 04:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAUREL HEIGHTSFACILITY NUMBER:
565850243
ADMINISTRATOR/
DIRECTOR:		JOHNNY ORTIZFACILITY TYPE:
740
ADDRESS:13960 PEACH HILL DRIVETELEPHONE:
(805) 292-0700
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 112CENSUS: 68DATE:
04/03/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Johnny OrtizTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced CASE MANAGEMENT- DEFICIENCIES visit to this facility and met with Executive Director, Johnny Ortiz. The case management visit is being conducted due to deficiencies observed during the investigation of complaint control # 29-AS-20241230123842. During the complaint investigation, the following deficiencies were observed:

During today’s visit LPA reviewed and compared the Personnel Report (LIC500), LIS system and the Guardian System. During the audit, LPA observed two (2) staff members listed on the Personnel Report (LIC500) that have passed a criminal background clearance, however, they were not properly associated to the facility. LPA was able to look-up employee information in the LIS system and found that Staff #1 has been working at the facility since 06/13/2022 and Staff #2 (S2) has been working since 05/16/2024. Both staff members were separated from facility named above. S1 separation date was 07/01/2023 and S2 was separated on 05/22/2023. ED stated that S1 is not longer an employee for the facility since 03/16/2025 and during today's visit S2 was associated to the facility. Additionally, LPA requested the Personnel Report (LIC 500) for the month of December 2024. However ED was unable to produce this information stating that they were not aware that the facility is required to keep a current roster of all facility personnel.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Citations issued, civil penalty issued, exit interview, appeal rights given.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/03/2025 04:45 PM - It Cannot Be Edited


Created By: Valeria Conway On 04/03/2025 at 03:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAUREL HEIGHTS
FACILITY NUMBER: 565850243

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/04/2025
Section Cited
CCR
87355(e)(3)

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87355(e)(1) Criminal Record Clearance
(e)...pursuant to Health and Safety Code Section 1569.17(b)...(1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
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Executive Director will associate staff members to the facility and/or update LIC 500 to remove emloyees that are not longer working in the facility.
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Based on record review and interview, LPA found 2 staff that were not associated to the facility. The licensee did not comply with the section cited above in 2 counts which poses an immediate health, safety or personal rights risk to persons in care.
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Deficiency Dismissed
Type B
04/11/2025
Section Cited
CCR87208(a)(5)

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87208(a)(5) Plan of Operation. (a)The licensee shall have and maintain a current, written definitive plan of operation for the facility... The plan and related materials shall contain the following: (5) Staffing plan, qualifications and duties.This requirement is not met as evidenced by:
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ED shall write a statement of understanding and complete/update a LIC 500 form when necessary and have it readily available for when licensing department request it. LPA expects administrator to have updated LIC 500 before POC due date.
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Based on observation and interviews ED did not comply with the above section by not ensuring plan of operation documentation is being kept readily available to licensing departments which poses a potential health, safety and personal rights risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
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